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KWAME NKRUMAH UNIVERSITY OF SCIENCE AND
TECHNOLOGY
PREVALENCE OF MALARIA IN GHANA: A CASE STUDY OF
THE BOSOMTWE-ATWIMA KWAWOMA DISTRICT IN THE
ASHANTI REGION.
A SUMMARY OF THESIS SUBMITTED TO THE DEPARTMENT
OF SOCIAL SCIENCES
IN PARTIAL FULFILMENT OF
BACHELOR OF ARTS (GEOGRAPHY AND RURAL
DEVELOPMENT)
COLLEGE OF ARTS AND SOCIAL KUMASI, GHANA
SUBMITTED BY
BENEDICTA OFOSUHEMAA ASANTE
2007
DECLARATION
I declare that I have personally undertaken this research under the supervision of Dr.
Mrs. Charlotte Mensah herein submitted.
I take full responsibility for errors, misinterpretation, misrepresentation and other
shortcomings.
…………………………………
BENEDICTA O. ASANTE
(Student)
May, 2007.
APPROVAL
I certify that I have supervised the student in undertaking the study herein and I confirm
that the student has my permission to present it for assessment.
…………………………….
Dr. Mrs. CHARLOTTE MENSAH
(Supervisor)
May, 2007.
DEDICATION
This dissertation is dedicated to my siblings Asante Sasu Sylvester, Asante Aboagyewaa
Grace and Asante Kwame Andrew, and the inhabitants of Bosomtwe-Atwima-Kwawoma
District most especially the people of Obo, Abono and Kuntanse.
ACKNOWLEDGEMENTS
Several people have helped me in the writing of this dissertation. First and foremost, I owe
a debt of gratitude to the Almighty God for giving me the strength and knowledge.
I am particularly grateful to Dr .Mrs. Charlotte Mensah, my supervisor, for the healthy
criticism, advice, instructions and useful suggestions I received from her.
I wish to register my deep appreciation to authors of the books, articles and journal I used
freely as references, especially Pro.Dr. Dr. .Bour’s Journal of the University of Science
and Technology Volume 13, WHO and GHS technical reports.
I also wish to record my acknowledgement to the contribution of various research studies
I conducted with Agyemang –Offei Robert, Asiamah Emmanuel and Wiafe Micheal.
My thanks also go to my parents Mr. and Mrs. Asante, my Grandmother, my Aunties, Mrs.
Mary Nkrumah Asante, Mrs.Christiana Asante and to my uncle Nana Adjei Francis for
their prayers and support and inspiration for my education.
Lastly, I wish to express my profound gratitude to Mr. David Assibi, the Medical Assistant
of Kuntanase General Hospital for his contribution to my research. To all my lecturers
especially Mr. J. Koomson, my friends and my classmates, I say thank you!
As for any errors, substantial or marginal which may be found in the dissertation, I am
entirely responsible for them.
ABSTRACT
Malaria ranks among the foremost health issues facing the world, especially tropical
countries. This endemicity of malaria has threatened health delivery services of the
country. Ashanti region records one of the highest malaria cases in the country. This
research studies the prevalence of malaria worldwide. The research further talks about the
incidence of malaria in the Lake Bosomtwe Area, and the history of the Bosomtwe-Atwima
Kwawoma district. In this paper, I explored the causes, effects, preventions and treatment
of malaria. Questionnaires were used in collecting data from selected respondents at a
random sampling. Specific attention was given to causes of malaria in the lake Bosomtwe
area as unsanitary practices, ignorance and lack of protective devices. Poverty and death
were explored in this research as the major effects of malaria on the inhabitants.
This study was concluded that, the causes of malaria can be prevented by taking necessary
precautions such as the use of treated mosquito nets, repellants and taking malaria vaccines.
In addition, it was discussed in the text that, malaria can be treated with the use of orthodox
and herbal medicine. Finally, this study recommends that, government and other agencies
should make it their ultimate aim to publicize the awareness of malaria in the Lake
Bosomtwe Area.
Key Words: District, fever, health, malaria, Ghana, Ashanti Region.
TABLE OF CONTENTS
Page
Declaration……..…………………………………………………………………………..ii
Dedication…..………………………………………………………………………….…..iii
Acknowledgement……………………………………………………………………….....iv
Abstract….……………………………………………………………………………….....v
Table of Contents……..………………………………………………………………....…vi
List of Tables….…………………………………………………………………………...viii
List of Abbreviations…….………………………………………………………….....…...ix
CHAPTER 1 Introduction……….…….………………………………………..…....1
1.1 Background………………………………………………………………......................1
1.2 Problem Statement………………………………………………………………….......2
1.3 Relevance of the study………………………………………………………………….3
1.4 Research Objectives…………………………………………………………………….4
1.5 Research Questions…………………………………………………………………......4
1.6 Conceptual Framework……………………………………………….…………….......4
1.7 Assumptions……………………………………………………..……………….……..6
1.8 Scope of study …………………………………………….…………………………....6
1.9 Organization of report ……………………………………………………………….…6
CHAPTER 2 Literature Review…………….……………………………………….7 2.1 Introduction…………………………………………………………………….……..…7
2.2 Global Burden of Disease………………………………………………………………..8
2.3 Human Related Factors…………………………………………………………………..9
2.4 Knowledge on Malaria……………………………………………………………….…10
2.5 Socio-Economic Factors……………………………………………………………...…11
2.6 Environmental Factors/Climate…………………………………………………………15
2.7 Causes of Malaria…………..…………………………………………………...………16
2.8 Life cycle of Plasmodium……………………………………………………..………...17
2.9 Pathogenesis of Malaria…………………………………………………………………17
2.10 Genetic Resistance……………………………………………………………..……....20
2.11 Clinic Features………………………………………………………………..………20
2.12 Diagnosis of Malaria……………………………………………………...……….…..22
2.13 Prevalence, Incidence & Determinants of Malaria………………………….…………23
2.14 Management of Malaria………………………………………………………………..24
CHAPTER 3 Methodology……………………………..…………..………………....26
3.0 Introduction…………………………………………………………………..............26
3.1 Political Background………………………………………………………..………..26
3.2 Geography………………………………………………………………….…...........26
3.3 History of Study Area………………………………………………….…………….27
3.4 Population Size…………….. ……………………………………….………………31
3.5 Study Design and Sample Size………………….…………………………………....31
3.6 Data Collection and Tools……………………………………………………..….….31
3.7 Pre-testing………………………………………………………………….…….…..31
3.8 Data Handling and Storage……………………………………………………….….32
3.9 Ethical Consideration…………………………………………………………….…..32
3.10Limitations………………………………………………………………………..…33
CHAPTER 4 Research Findings…………………………..…………..…………..…34
4.0 Introduction………………………………………………………………………...34
4.1 Demographic Characteristics of Respondents……………………………….…..…34
4.2 Malaria Prevalence……………………………………………………………...…..38
4.3 Causes of Malaria Prevalence………………………………………….………..….39
4.4 Effects on Malaria Prevalence……………………………………….………..……40
4.5 Treatment and Prevention of Malaria Prevalence……………………………..…....41
4.6 Health Official Response…………………………………………………….….….42
CHAPTER 5 Summary, Conclusions and Recommendations………………......43
5.1Summary of Major Findings…………………………………………….………….43
5.2Conclusions……………………………………………………………..…………..43
5. 3Recommendations……………………………………………………………….…44
5.4 Limitations of the Study……………………………………………………..…….45
5.5 Suggestion for Future Research……………………………….…………………...45
LIST OF BIBLOGRAPHY………………………………………………….…….…46
LIST OF TABLES, FIGURES AND PLATES
TABLE PAGE
4.1 Educational Background of Respondents …………….……………………….....35
4.2 Age of Respondents..……………………………….……………………………36
4.3 Occupations of the Respondents…………………...………………………….…37
4.4 Sex of Respondents…………………………………………………………....….38
4.5 Prevalence of Malaria………………………………………………………..……38
4.6 Response of Causes of Malaria……………………………...……………….…...39
4.7 Response of Effect of Malaria……………………………………...……….……40
4.8 Response of Treatment and Prevention of Malaria………………………….……41
FIGURE
1.1 Conceptual Framework……………………………………………………..…...5
3.1 Map of Bosomtwe-Atwima Kwanwoma District………………..………….....30
PLATES
1 An overview of Lake Bosomtwe………………………………………...34
2 An Anopheles Mosquito……………………………...………………….40
LIST OF ABBREVIATIONS
ACTs Artemisinin Based Combination Therapy
DALYs Disability Adjusted Life Years
GHS Ghana Health Service
IPTp Intermittent preventive therapy in pregnancy
ITNs Insecticide-treated mosquito nets
LLITNs Long Lasting Insecticide Treated Nets
MOHsw Ministry of Health and Social Welfare
MOP Malaria Operational Plan
NIMR National Institute of Medical Research
NMCP National Malaria Control Programme
NMTSP Natinal Malaria Medium Term Strategic Plan
RBM Roll Back Malaria
RDTs Rapid Diagnostic Tests
UNDP United Nations Development Programme
UNICEF United Nations Children Education Fund
WHO World Health Organization
CHAPTER ONE
1.1 INTRODUCTION
Malaria ranks among the major health and development challenges facing some of the
poorest economies. Endemic in ninety-one countries, accounting for forty percent of the
world’s population, malaria affects an estimated three hundred million people. Though in
most cases treatable, malaria is responsible for more than a million deaths per year. In Sub-
Saharan Africa, the most affected region, malaria related illnesses claim the life of one out
of every twenty children below age five. For adults, mortality rates are lower but frequent
debilitating attacks reduce the quality of life for chronic sufferers
(www.who/malaria.html).
In the last decade, the prevalence of malaria has been escalating at an alarming rate,
especially in Africa. An estimated 300-500 million cases each year cause 1.5 to 2.7 million
deaths; more than 90% of the deaths are in children under 5 years of age in Africa. Malaria
(9% of global disease burden) ranks third among major infectious disease threats in Africa
after pneumococcal acute respiratory infections (3.5%) and tuberculosis (TB)
(2.8%). Malaria cases in Africa account for approximately 90% of malaria cases in the
world. Between 1994 and 1996, malaria epidemics in 14 countries of Sub-Saharan Africa
caused an unacceptably high number of deaths, many in areas previously free of the
disease. Adolescents and young adults are now dying of severe forms of the disease
(www.malaria.org).
The partial success of the eradication programs resulted in a sharp spatial concentration of
malaria in tropical areas. The same areas also suffer most from a set other illnesses related
to the economic development stage [Sachs (1997, 1999), Gallup and Sachs (1998a, b)],
including intestinal diseases causes by contaminated water and communicable diseases
such as tuberculosis.
As a primarily rural parasitic disease transmitted by mosquito bites, malaria is less
immediately affected by improved urban sanitation and housing in the course of economic
development; indeed, after the failure of the eradication efforts, malaria has at times been
portrayed as a largely unavoidable side effect of tropical location.
Malaria, debilitating infectious disease characterized by chills, shaking, and periodic bouts
of intense fever. Caused by single-celled parasites of the genus Plasmodium, malaria is
transmitted from person to person by the bite of female mosquitoes (www.malaria.org).
Although malaria was once widespread in North America and other temperate regions, the
last major outbreak of malaria in North America occurred in the 1880s. The disease today
occurs mostly in tropical and subtropical countries, particularly sub-Saharan Africa and
Southeast Asia. According to the World Health Organization, malaria is prevalent in over
100 countries. Each year more than 300 million cases of malaria are diagnosed, and more
than 1.5 million die of the disease.
1.2 PROBLEM STATEMENT
The Bosomtwe district in the Ashanti Region of Ghana is a peri-urban district which is
located south of the Kumasi metropolis. The tribe is largely of the Asantes. The population
that is unemployed is high. Malaria poses a serious health problem in Ghana; it is
hyperendemic with a crude parasite rate ranging from 10 – 70% and plasmodium
falciparum the major malaria parasite, dominating. Although numerous efforts have been
made to fight malaria in the country and the district at large, as in many endemic countries,
achievements have been minimal. It is the number one cause of morbidity accounting for
40% of outpatient attendance with annual reported cases of 2.2 million between 1995 -
2001, and over 10% ending up on admission (Kusi 2003). From the UN classification of
childhood diseases it ranks third in Africa (Ministry of Health 2002). Lake Bosmtwe, the
only Crater Lake is situated in the Amakom sub – district. The district has a stretch of
weeds long river body, this and many activities of the inhabitants assist in the bleeding of
the female mosquitoes, hence increase in the prevalence of malaria in the district. The
perception is that prevalence of malaria in the Lake Bosomtwe district is as a result of the
daily activities of inhabitants, hence the research work.
1.3 RELEVANCE OF THE STUDY
Lake Bosomtwe is one of the biggest natural lakes in Africa. Lake Bosomtwe is one of the
most important tourist attraction centers in Ashanti region and Ghana as a whole serving
as a foreign exchange earner to the economy of Ghana. It is about 30 minutes’ drive that is
31km away from Kumasi. Tourists love the lake because a range of mountains surrounds
it. It makes great fun for tourist to stand along the crater and watch the fishing folks
paddling the carved boats or canoes.
Tourists are giving the chance to ride on the Lake for 45-50 minutes. The revenue generated
from this is use for the development of the area, making this study very important. The
study will also benefit the residents living in this area since it seeks to address the causes
and preventions of malaria .The study will also add to existing literature on malaria in
Ashanti region and Ghana as a whole.
1.4 RESEARCH OBJECTIVES
The main objective is to determine the prevalence of malaria in Lake Bosomtwe
The specific objectives include:
1. To determine the causes of malaria in lake Bosomtwe
2. To ascertain the effect of malaria on the people living in this area
3. To identify the possible prevention methods of malaria in lake Bosomtwe
1.5 RESEARCH QUESTIONS
1. What are the causes of malaria in Lake Bosomtwe?
2. How are the people affected by the incidence of malaria in the district?
3. What are the possible prevention methods of malaria?
1.6 CONCEPTUAL FRAMEWORK
Malaria is endemic and a clinical disease in the Lake Bosomtwe Area. Malaria is usually a
human cause disease. The conceptual framework in figure 1.1 helps in understanding how
malaria is cause and its effects on the people of the study area. This conceptual framework
reveals that, malaria is cause by poor sanitation. Figure 1.1 illustrates poor sanitation such
as stagnant water in cans, gutters and disposed ties. The throwing of faces around our
surroundings and bushy surroundings. These areas serve as breeding places for the
Anopheles mosquitoes. The inhabitants when biting by these mosquitoes exhibits
symptoms such as fever, chills, high temperature and headache, hence malaria infections.
Figure 1.1: Conceptual Framework
(Construct of Author, 2007)
MALARIA
Stagnant water in cans
Gutters and disposed ties
Throwing of sewage and faeces around surroundings
Breeding of the female Anopheles Mosquitoes
Anopheles mosquitoes bites inhabitants
The inhabitants get fever, chills, high temperature,
and headache
Bushy surroundings
1.7 ASSUMPTIONS
1. Malaria is a disease that is both preventable and curable.
2. The prevalence of malaria has caused poverty.
1.8 SCOPE OF STUDY
The study covered the whole of the district. It involved all the 21 villages; inhabitants,
opinion leaders, and healthcare officers in the district.
1.9 ORGANIZATION OF REPORT
Chapter one has presented the background information to the study, the problem statement
and the justification for the study the objectives. Chapter two presents a review of related
literature on the level of knowledge about the malaria, life cycle of plasmodium and
pathogenesis, causes of malaria, scientific classification of mosquitoes, management of
malaria, prevalence, incidence and determinants of malaria, diagnosis of malaria, clinical
features and genetic resistance. Chapter three describes the profile of the study area, the
study type and population chosen and the general procedure that the study followed.
Chapter four presents the results and discussions and chapter five, the conclusions and
recommendations of the study.
CHAPTER TWO
2.0 LITERATURE REVIEW
This chapter deals with the review of relevant literature to the study.
2.1 INTRODUCTION
From the study of Nayyar, et al (2006), Malaria is a mosquito-borne infectious disease of
humans and other animals caused by arasitic protozoans (a type of unicellular
microorganism) of the genus Plasmodium. Commonly, the disease is transmitted via a bite
from an infected female Anopheles mosquito, which introduces the organisms from its
saliva into a person's circulatory system. In the blood, the protists travel to the liver to
mature and reproduce. Malaria causes symptoms that typically include fever and headache,
which in severe cases can progress to coma or death. The disease is widespread in tropical
and subtropical regions in a broad band around the equator, including much of Sub-Saharan
Africa, Asia, and the Americas. Five species of Plasmodium can infect and be transmitted
by humans. The vast majority of deaths are caused by P. falciparum and P. vivax, while
P. ovale, and P. malariae cause a generally milder form of malaria that is rarely fatal. The
zoonotic species P. knowlesi, prevalent in Southeast Asia, causes malaria in macaques but
can also cause severe infections in humans. Malaria is prevalent in tropical and subtropical
regions because rainfall, warm temperatures, and stagnant waters provide habitats ideal for
mosquito larvae. Disease transmission can be reduced by preventing mosquito bites by
using mosquito nets and insect repellents, or with mosquito-control measures such as
spraying insecticides and draining standing water.
Malaria is typically diagnosed by the microscopic examination of blood using blood films,
or with antigen-based rapid diagnostic tests. Modern techniques that use the polymerase
chain reaction to detect the parasite's DNA have also been developed, but these are not
widely used in malaria-endemic areas due to their cost and complexity. The World Health
Organization has estimated that in 2010, there were 219 million documented cases of
malaria. That year, the disease killed between 660,000 and 1.2 million people, many of
whom were children in Africa. The actual number of deaths is not known with certainty,
as accurate data is unavailable in many rural areas, and many cases are undocumented.
Malaria is commonly associated with poverty and may also be a major hindrance to
economic development. Despite a need, no effective vaccine exists, although efforts to
develop one are ongoing. Several medications are available to prevent malaria in travellers
to malaria-endemic countries (prophylaxis). A variety of antimalarial medications are
available. Severe malaria is treated with intravenous or intramuscular quinine or, since the
mid-2000s, the artemisinin derivative artesunate, which is superior to quinine in both
children and adults and is given in combination with a second anti-malarial such as
mefloquine. Resistance has developed to several antimalarial drugs; for example,
chloroquine-resistant P. falciparum has spread to most malarial areas, and emerging
resistance to artemisinin has become a problem in some parts of Southeast Asia (Nayyar,
et al, 2006).
2.2. GLOBAL BURDEN OF DISEASE
Malaria is considered the most consequential parasitic infection in humans. There are as
many as 350-500 million clinical episodes per year worldwide (UNICEF, 2003) and while
most estimates of mortality caused by malaria lie at around 1 million deaths per year (Snow
et al. 2005), some calculations go as high as 3 million (Breman et al, 2004). Almost all of
these deaths occur in children (Phillips, 2001), living in malarious countries in sub-Saharan
Africa (SSA) (Ukoli, 1990) where 25% of all childhood mortality below the age of five
(about 800,000 young children (Shepard et al., 1991) is attributable to malaria. Of those
children who survive cerebral malaria, more than 15% suffer neurological deficits (NIMR
2006, & Schönfeld et al, 2007) which include weakness, spasticity, blindness, speech
problems and epilepsy. Where such children are poorly managed and do not have access
to specialized educational facilities, these deficits may interfere with future learning and
development Children under the age of five years are at highest risk for malaria because
they have not yet acquired protective immunity. People with semi-immunity are infected,
but do not get a severe disease as a rule. In stable transmission areas newborns are protected
by the IgM antibodies of their mother and through breastfeeding. After three months
children have a higher susceptibility for an infection with the parasite. In high transmission
areas this time period lasts until the age of 3-5 years. In areas with a seasonal transmission
the period can last 10 years. Without re-infection the acquired immunity can dissapear in a
matter of years (Eddleston et al. 2008).Furthermore children under five years of age
experience the biggest malaria burden because they are often super-infected with other
parasites and/or that they often suffer from nutritional deficiencies. These lead to a weaker
immune system, which leads to a higher susceptibility for malaria. Moreover, a malaria
infection and malnutrition are reasons for an increasing anaemia burden in children
(Greenwood et al.1991).
2.3 HUMAN RELATED FACTORS
There is a large amount of data on malaria related morbidity and mortality in children under
five. (Menard et al, 2010) suggested that, the risk of infection and its severity is lower in
the first few months of life. Reasons for this are complex but probably include transmission
of protective antibodies across the placenta, the presence of red cells containing Hbf –
which are relatively resistant to malaria infection, breast feeding and lack of exposure
(Hviid, & Staalsoe T.2004).The protective effect of maternal antibody is likely to be less
when effective malaria control is achieved and the overall level of malaria infection
declines. In lower transmission settings clinical malaria is spread more widely across the
age groups. In such settings, occupational issues may become more important than age;
this is especially true where mosquitoes which transmit malaria bite outdoors away from
dwellings. Forest workers in south-east Asia are one example of this phenomenon (Erhartet
al, 2004). In these settings young adults, especially males, may be more at risk than
children; because they are the group at most risk from being bitten by forest dwelling
vectors (Dysoley et al, 2008). Furthermore this information was supported by a study that
was done in Kenya that explored factors affecting use of permethrin-treated bed nets during
a randomized controlled trial found that children less than five years of age were less likely
to use nets compared to the individual adults (Alaii et al, 2003).
2.4 KNOWLEDGE ON MALARIA
A number of studies have investigated differences in knowledge and reported health
seeking behavior between men and women. Most found either no difference or those
women had more limited decision-making and financial power to act. This was associated
with failures and delays in seeking treatment, with differential understanding of malaria
between men and women, and differential health-seeking behaviour. Women delayed
seeking care until men were available, while men were less willing to spend on child health.
(Al-Taiar et al 2007 & Oberlander and Elverdan 2000).These differences are critical when
considering the main child-caring role of women and children‘s increased vulnerability to
malaria. Furthermore according to (Minja et al., 2001), it was stated that knowledge,
attitude and behavior practices regarding malaria were shown to influence the ITN
ownership. Some other studies that were done by
(Victora, 2003, Nganda 2004&Magesa et al., 2005) reported that knowledge of the
problem; affordability and accessibility are among major obstacles for the ITN ownership
and use. Net ownership has also been related to the educational levels of household
members. This is a complicated relationship since educational attainment can have the
impact on an individual‘s ability to understand and access information regarding malaria
prevention methods. In Malawi it was found that net ownership was less common in
households where the head/caretaker had not completed primary school and in homes
where the house had mud walls or a grass roof (Holtz et al., 2002). This is being supported
by (Nuwaha, 2001) with evidence that educational attainment is associated with malaria-
specific knowledge and uptake of preventive measures. Rhoida Y et al 2004concluded that
the success in implementing preventive interventions amongst pregnant women in
Tanzania is thus likely to be determined in part by awareness of malaria and the strategies
available to prevent it. In order for the ITN distribution programme to succeed, the
knowledge gaps, practices and attitudes that may negatively influence the intervention
uptake.
2.5 SOCIO-ECONOMIC FACTORS
Socioeconomic conditions of the community have direct bearing on the problem of malaria.
Ignorance and impoverished conditions of people contribute in creating source and spread
of malaria and hinder disease control strategy (Collins et al, 1997&Yadav et al., 1999).
This was also evidenced by Filmer 2002, that high costs of malaria treatment may lead to
delays in treatment seeking behavior, whereby he found that the poorest groups in a society
did not seek care as much as the non-poor, and did so at lower level public facilities.
Economic inequities in areas such as the control of household resources also affect access
to ITNs. In one study in Benin, many women explained that since they were financially
dependent on their husbands, they were unable to purchase an ITN for themselves and their
children unless their husbands prioritized the use of bednets (Krause G, et al 2000)).The
study also revealed that when women did earn an income and had control over this income,
they were much more likely than men to purchase an ITN for their household.(Krause G,
et al 2000) Alnwick 2000,also observes that malaria afflicts primarily the poor, who tend
to live in dwellings that offer little or no protection against mosquitoes. Furthermore,
(Brown, 1997) notes that ―the continuation of brutal poverty and hunger in much of the
world is undoutbtedly linked to large numbers of unnecessary deaths from malaria. A
survey in Zambia also found a substantially higher prevalence of malaria infection among
the poorest population groups (Roll Back Malaria, 2001). According to (Makundi et
al,2007) it was reported that the burden of malaria is greatest among poor people, imposing
significant direct and indirect costs on individuals and households and pushing households
into in a vicious circle of disease and poverty. Furthermore, vulnerable households with
little coping and adaptive capacities are particularly affected by malaria. Households can
be forced to sell their food crops in order to cover the cost of treatment (Wandiga et al,
2006.) Depleting household resources and leading to increased food shortages, debts, and
poverty for the poorest households. The costs of malaria are highly regressive, with the
poorer households spending a significantly higher proportion of their income on the on the
treatment of malaria than their least poor counterparts.
In Ghana, both direct and indirect costs associated with a malaria episode represent a
substantial burden on poorer households. A study found that while the cost of malaria care
was just 1 per cent of the income of the rich, it was 34 percent of the income of poor
households (Akazili, 2002). Similarly, (Kuate,1997) found that the burden of illness rests
disproportionately on the economically disadvantaged women who were not employed,
women living in poor neighbourhoods, and those living in households without modern
facilities. This is being supported by a study that was done on the use of ITNs whereby it
was only recently appreciated that a net treated with insecticide offers much greater
protection against malaria. Unfortunately, the commercial price of nets and insecticide is
beyond the poorest income groups of the population (World Health Organization, 2003).
Ziba et al 1994: found that in Malawi, use of malaria prevention measures (bednets,
insecticides, mosquito coils, other insect repellents, burning leaves, etc) was income-
dependent. In households where the head earned a larger than average income, use of
commercial methods (mosquito coils, insecticide spray, bednets) was more common. Use
of inexpensive and less effective, natural methods (burning leaves, dung, or wood) was
associated with lower income. Occupational and cultural differences related to undertaking
activities likely to lead to malaria transmission; and when malaria is acquired, access to
health services is more mixed and varies considerable across different cultural settings.
Alternatively, if a household only has one bednet, priority may be given to the male head
of the household as he is often considered the primary breadwinner (Krause, et al 2000).
Before the ITNs project started in Bagamoyo, Tanzania, it was reported that it was mainly
the adult men who used the nets, followed by women and children under two who sleep
with their mothers, while elder children were frequently the last to gain access (Makemba
et.al.1995). ITNs availability and efficacy. The use of insecticide-treated nets is currently
considered one of the most cost-effective methods of malaria prevention in highly endemic
areas Tanzania being included. This has been achieved through free distribution of long
lasting insecticidal nets (ITNs) that has been conducted through campaigns, public health
facilities, faith-based organisations (FBO), and non-governmental organisations (NGOs)
with the goal of achieving universal access for the at-risk population of children under age
five and pregnant women. The use of ITNs in Tanzania has increased markedly over the
past few years. Statistics indicate that the proportion of households with at least one
untreated net has increased from 14% in 2001 to 58% in 2005.ITNs coverage is estimated
to have reached 63% of households with at least one ITN and 25%b and 26% of children
under 5and pregnant were respectively sleeping under an ITN. However, more effort is
needed to further increase this to reach the globally agreed target of 80(2007-2008
YHMIS). According to the (MoHSW 2006) report, Insecticide-treated mosquito nets
(ITNs) used for protection against mosquito bites has proven to be a practical, highly
effective, and cost-effective intervention against malaria. This was also supported by (Roll
Back Malaria, 2005) which reported that ITNs reduces human contact with infected
mosquitoes and have been shown to be an effective malaria prevention measure. In addition
to the direct benefit to the individual, ITNs use offers a protective benefit for the entire
community (Teklehaimonot et al., 2007). Studies examining ITN‘s efficacy suggest a
significant reduction in malaria episodes. If used universally, ITNs could prevent
approximately 7% of the global under-five mortality (Jones et al, 2003). The UNICEF
corroborates that under-five mortality rates could be reduced by about 25-30% if all young
children in malaria endemic areas were protected by treated bed nets at night. This was
also evidenced by (Lengeler‘s,2004) review which demonstrates the efficacy of ITNs in
both stable and unstable transmission areas where by it was documented the wide spread
use of ITNs resulted in an overall reduction in mortality of 19 percent, protected against
anemia, and had a substantial impact on mild disease episodes. Another One large-scale
rural study in Tanzania found that ITNs and untreated nets reduced mortality of children
one month to four years, with protective efficacies of 27 and 19 percent, respectively
(Armstrong and Schellenberg,2002). Hill et al wrote in 2006 that despite of all these efforts
and its efficacy, only 3% of African children sleep under these treated nets while only about
20% sleep under any other kind of nets. This however may account for the high rate of
mortality amongst children due to malaria and its related problems. Despite the evidence
that the use of ITNs decreases malaria-related morbidity and mortality, the use of ITNs in
sub-Saharan Africa remains relatively low.
2.6 ENVIRONMENTAL FACTORS/CLIMATE
Malaria is governed by a large number of environmental factors, which affect its
distribution, seasonality and transmission intensity (Snow et al, 1999). Climate and
environmental conditions greatly affect the transmission and incidence of malaria, by
influencing primarily the abundance and survival of vectors and parasites, and also
exposure of humans and other hosts. (Lafferty, 2009). The most important environmental
factors for malaria transmission have to do with conditions for Anopheles mosquito
breeding and survival water in which they can breed, and minimum temperatures and
humidity to allow them to survive long enough for the vector stage of the parasite‘s life
cycle to be completed usually about ten days. These factors are influenced by climate, as
well as by topography and soil conditions, drainage, vegetation cover, land use and water
all of which vary greatly depending on local conditions. As such, changes in climate and
land use such as water management, agriculture, urbanization, and deforestation can lead
to significant increases or decreases in malaria transmission, depending on local contexts.
(Reiter P.2001) Some agricultural practices facilitate the spread of vector-borne diseases.
Also, the presence of cattle in marshy areas results in the creation of hoof prints that
potentially offer ideal conditions for mosquito breeding. Within man- made malaria,
excluding the migration of non-immunes to endemic areas, the most important impacts on
transmission are probably brought about by water resource development and land use
change. Human modification to the environment also can create larval development sites
and malaria (Denise et al, 2003). This may especially be true for man- made malaria in
which man by his farming activity or any other activity may create the environments which
suit mosquito breeding and protective measures may be widely distributed. The
identification of predictors of malaria incidence could provide a useful means of
identifying targets for intervention of manmade malaria (Ghebreyesus et al., 2000).
Furthermore Utilization of ITNs has, however, been found to vary with Binka et al showed
seasons of the year and acceptability of the nets in terms of size, colour and shape. That
the time of the year during which the nets are delivered affects use. 99% of the net
recipients were found to use the nets during rainy season, while only 20% used it during
the dry season this was evidenced by a study which was done in Burkina Faso of which
reported a decreased use of bed nets during the dry season due to a perceived lower risk of
mosquito bites and the practice of sleeping outdoors (Frey et al, 2006). Malaria control
strategies need to consider how changing environmental conditions may be linked to an
increase or decrease of malaria transmission. Opportunities exist for integrating
environmental management interventions into vector control strategies in order to reduce
malaria risk.
2.7. CAUSES OF MALARIA
Malaria parasites belong to the genus Plasmodium (phylum Apicomplexa). In humans,
malaria is caused by P. falciparum, P. malariae, P. ovale, P. vivax and P. knowlesi. Among
those infected, P. falciparum is the most common species identified (~75%) followed by
P. vivax (~20%). Although P. falciparum traditionally accounts for the majority of deaths,
recent evidence suggests that P. vivax malaria is associated with potentially life-threatening
conditions about as often as with a diagnosis of P. falciparum infection. P. vivax
proportionally is more common outside of Africa (Okenul, 2003). There have been
documented human infections with several species of Plasmodium from higher apes;
however, with the exception of P. knowlesi—a zoonotic species that causes malaria in
macaques—these are mostly of limited public health importance (Okenul, 2003).
2.8 LIFE CYCLE OF PLASMODIM
All types of malaria have a similar life cycle. Sporozoites, the infectious form of the malaria
parasite, are injected into a human host through the saliva of an Anopheles mosquito. These
sporozoites enter the liver cells within minutes, take on a new form, and multiply. When
the liver cells rupture, blood stage parasites—known as merozoites—are released. Each
merozoite invades a red blood cell, and for two days multiplies into more merozoites. The
red blood cell full of merozoites ruptures to release more merozoites. It is this stage of the
life cycle that causes disease and, too often, death. Some merozoites change into the form
called gametocytes, which do not cause disease but remain in the blood until they are
cleared by drugs or the immune system, or taken up by the bite of a mosquito. In the
mosquito's stomach a "male" gametocyte fertilizes a "female" to form an egg, or oocyst,
which matures into thousands of sporozoites that swim to the mosquito's salivary glands to
be injected into another human at the next bite (Gallup, 2001).
2.9 PATHOGENESIS OF MALARIA
In humans, malaria is caused by four species of the plasmodium protozoa (single celled
parasites) – plasmodium falciparum, plasmodium vivax, plasmodium ovale and
plasmodium malariae. Of these species plasmodium falciparum accounts for the majority
of infections and is the most lethal. Several studies have been done on different aspects of
the disease, from parasitology to finding a cure with drugs (chemotherapy) and to
eradication of the disease by the use of insecticide treated net and insecticides. Rashed4
conducted a study which was aimed at determining the effect of Permethrin insecticide
treated nets (PITN) use on the incidence of febrile episodes and non-household malaria
expenses in Benin. The study found out that, the use of PITNs decreased the risk of
developing malaria by 34% in children in the rural areas; meanwhile, PITN use did not
reduce prevention and treatment expenses. In a parasitology laboratory, malaria was found
to be the major killer of paediatric illness and death in Kinshasa (Coene 1991).
In view of this, the treatment of fevers as malaria with chloroquine is no longer acceptable
because the plasmodium falciparum had a resistance to chloroquine. According to the
study, the differences in endemicity of malaria that existed between the various parts of
town had to be taken into consideration alongside the ecological and socio-economic
factors that underlie when planning for estimation of potential control methods. The
behavioural risk for malaria in the Machodinho resettlement area in the Amazonian forests
of Brazil was examined (Castilla and Sawyer 1993). Analysis of the study suggested that
economic status and knowledge of the importance and behavoiur of the mosquito in
transmitting malaria are significant factors in determining prevalence risk irrespective of
whether preventive precautions, for example, dichlorodiphenyl trichloroethane (DDT)
spraying of houses and cleaning of vector breeding sites are to be undertaken in the
endemic areas. However, the researchers found out that a higher economic status combined
with better knowledge of the vector and DDT spraying of houses decreased the risk of
infection. They suggested that a more positive implication is that control programmes must
work harder and more intensively on behalf of poorer people especially migrants in order
to diminish the disease burden for them. Sharma and colleagues (2001) carried out a study
on the socioeconomic factors as well as on the human behaviour towards malaria on cross
section of the Sundargarh district in India. They argued that poor socioeconomic status and
socio-cultural factors play an important role in maintaining high degree of malaria
transmission. They found that human behaviours such as location of hamlets, type of
malaria transmitted, sleeping habits, and outdoor activities after dusk, poor knowledge
about the disease and treatment seeking behaviour are of great significance as determinants
of malaria transmission.
Malaria is also a major problem in Papua New Guinea as it accounts for a high proportion
of sickness and death. This is because in addition to human suffering, it also put severe
stress on the health facilities and directly hinders economic growth. It has been suggested
that a malaria vaccine would be best, most cost effective and safe public health measure to
reduce the burden of malaria (Reeder 2001). Whitty and Allan (2004) contend that the
serious threat posed by the spread of drug-resistant malaria in Africa has been widely
acknowledged. Chloroquine resistant malaria is now almost universal and resistant to
successor drug, sulfadoxine-pyrimethamine (SP) is growing rapidly. If the question of cost
of treatment is not successfully addressed this could lead to adverse result from the
deployment of combination therapy as a first-line treatment. Adverse effect of costly
treatment ranges from increase in delays in infected individuals presenting themselves to
the health care facilities for treatment to exclusion of the poorest malaria sufferers from
receiving treatment altogether.
2.10. GENETIC RESISTANCE
According to a 2005 review, due to the high levels of mortality and morbidity caused by
malaria—especially the P. falciparum species—it has placed the greatest selective pressure
on the human genome in recent history. Several genetic factors provide some resistance to
it including sickle cell trait, thalassaemia traits, glucose-6-phosphate dehydrogenase
deficiency, and the absence of Duffy antigens on red blood cells (Kwiatkowski, 2005). The
impact of sickle cell trait on malaria immunity illustrates some of the evolutionary trade-
offs that have occurred because of endemic malaria. Sickle cell trait causes a defect in the
hemoglobin molecule in the blood. Instead of retaining the biconcave shape of a normal
red blood cell, the modified hemoglobin S molecule causes the cell to sickle or distort into
a curved shape. Due to the sickle shape, the molecule is not as effective in taking or
releasing oxygen. Infection causes red cells to sickle more, and so they are removed from
circulation sooner. This reduces the frequency with which malaria parasites complete their
life cycle in the cell. Individuals who are homozygous (with two copies of the abnormal
hemoglobin beta allele) have sickle-cell anaemia, while those who are heterozygous (with
one abnormal allele and one normal allele) experience resistance to malaria. Although the
shorter life expectancy for those with the homozygous condition would not sustain the
trait's survival, the trait is preserved because of the benefits provided by the heterozygous
form (Kwiatkowski, 2005).
2.11 CLINICAL FEATURES
The signs and symptoms of malaria typically begin 8–25 days following infection;
however, symptoms may occur later in those who have taken antimalarial medications as
prevention. Initial manifestations of the disease—common to all malaria species—are
similar to flu-like symptoms, and can resemble other conditions such as septicemia,
gastroenteritis, and viral diseases. The presentation may include headache, fever, shivering,
joint pain, vomiting, hemolytic anemia, jaundice, hemoglobin in the urine, retinal damage,
and convulsions (Sherman, 1998).
The classic symptom of malaria is paroxysm—a cyclical occurrence of sudden coldness
followed by shivering and then fever and sweating, occurring every two days (tertian fever)
in P. vivax and P. ovale infections, and every three days (quartan fever) for P. malariae.
P. falciparum infection can cause recurrent fever every 36–48 hours or a less pronounced
and almost continuous fever. Severe malaria is usually caused by P. falciparum (often
referred to as falciparum malaria). Symptoms of falciparum malaria arise 9–30 days after
infection.[4] Individuals with cerebral malaria frequently exhibit neurological symptoms,
including abnormal posturing, nystagmus, conjugate gaze palsy (failure of the eyes to turn
together in the same direction), opisthotonus, seizures, or coma (Sachs, 2001).
2.11.1. Complications
There are several serious complications of malaria. Among these is the development of
respiratory distress, which occurs in up to 25% of adults and 40% of children with severe
P. falciparum malaria. Possible causes include respiratory compensation of metabolic
acidosis, noncardiogenic pulmonary oedema, concomitant pneumonia, and severe
anaemia. Although rare in young children with severe malaria, acute respiratory distress
syndrome occurs in 5–25% of adults and up to 29% of pregnant women. Coinfection of
HIV with malaria increases mortality. Renal failure is a feature of blackwater fever, where
hemoglobin from lysed red blood cells leaks into the urine (WHO, 1999).
Infection with P. falciparum may result in cerebral malaria, a form of severe malaria that
involves encephalopathy. It is associated with retinal whitening, which may be a useful
clinical sign in distinguishing malaria from other causes of fever. Splenomegaly, severe
headache, hepatomegaly (enlarged liver), hypoglycemia, and hemoglobinuria with renal
failure may occur. Malaria in pregnant women is an important cause of stillbirths, infant
mortality and low birth weight, particularly in P. falciparum infection, but also with
P. vivax (WHO, 2005).
2.12 DIAGNOSIS OF MALARIA
Owing to the non-specific nature of the presentation of symptoms, diagnosis of malaria in
non-endemic areas requires a high degree of suspicion, which might be elicited by any of
the following: recent travel history, enlarged spleen, fever, low number of platelets in the
blood, and higher-than-normal levels of bilirubin in the blood combined with a normal
level of white blood cells. Malaria is usually confirmed by the microscopic examination of
blood films or by antigen-based rapid diagnostic tests (RDT) (Perking, 2007). Microscopy
is the most commonly used method to detect the malarial parasite; about 165 million blood
films were examined for malaria in 2010. Despite its widespread usage, diagnosis by
microscopy suffers from two main drawbacks: many settings (especially rural) are not
equipped to perform the test, and the accuracy of the results depends on both the skill of
the person examining the blood film and the levels of the parasite in the blood. The
sensitivity of blood films ranges from 75–90% in optimum conditions, to as low as 50%.
Commercially available RDTs are often more accurate than blood films at predicting the
presence of malaria parasites, but they are widely variable in diagnostic sensitivity and
specificity depending on manufacturer, and are unable to tell how many parasites are
present (WHO, 2004).
In regions where laboratory tests are readily available, malaria should be suspected, and
tested for, in any unwell patient who has been in an area where malaria is endemic. In areas
that cannot afford laboratory diagnostic tests, it has become routine to use only a history
of subjective fever as the indication to treat for malaria; a presumptive approach
exemplified by the common teaching "fever equals malaria unless proven otherwise". A
drawback of this practice is over diagnosis of malaria and mismanagement of non-malarial
fever, which wastes limited resources, erodes confidence in the health care system, and
contributes to drug resistance. Although polymerase chain reaction-based tests have been
developed, these are not widely implemented in malaria-endemic regions as of 2012, due
to their complexity (Gallup et al, 2001).
2.13 PREVALENCE, INCIDENCE AND DETERMINANTS OF MALARIA
It should be noted that epidemic malaria is derived from interactions of vectors, parasites
and various environmental and anthropogenic determinants. Malaria epidemic afflict
immunological vulnerable populations, straining the capacity of health facilities and
causing case fatality rates to increase five-fold or more during outbreaks. The demographic
profile may translate into larger economic consequences, although the full economic
impact of epidemic malaria remains undefined. A study was conducted in Benin on how to
conceive and establish the importance of economic factors that contributed to malaria
transmission (Mensah and Kumaranayake 2004).
According to the study, despite the endemic malaria situations, there was still little
understanding of the relative importance of economic factors that contribute to people
acquiring the disease in communities where malaria was endemic. The researchers
contended that, predisposing characteristics of household’s heads such as age, knowledge
of malaria, education and size of household significantly affect the incidence of malaria as
anticipated by economic theory. A study by Asenso – Okyere (1994) on malaria in 4
districts namely Kojo Ashong, Barekese, Barekuma and Oyereko all from the Greater
Accra Region of Ghana revealed that factors that were perceived as causing malaria are
malnutrition, mosquitoes, excessive heat, excessive drinking, flies, fatigue, dirty
surroundings, unsafe water, bad air and poor hygiene. Almost all the adolescents at that
time had no idea how the disease was spread from person to person, while the symptoms
of clinical malaria was also frequently considered to be yellowish eyeball, chills and
shivering, headache, a bitter taste, body weakness and yellowish urine, the study added.
2.14 MANAGEMENT OF MALARIA
Yeboah-Antwi and colleagues (1997) examined the extent to which district health teams
in Kintampo in the Brong Ahafo Region of Ghana could reduce the burden of malaria,
which is a major cause of mortality and morbidity in a situation where severe resource
constraints existed. It was found out that, compliance improve by approximately 20% in
both adults and children but there was improvement to care about 50% for example in cost
to patients, waiting time at dispensaries and drug wastage at facilities. Another case study
in Ghana sought to compare household’s data on acute morbidity and treatment seeking
behaviour in two districts with the use of health facility data (Agyepong and Kangeya-
Kayonda 2004). For every case of febrile illness seen in the health facilities there were
approximately 4-5 cases in the community, hence they concluded that every febrile
episodes especially in children be treated with an anti-malarial drug. Since several
countries extend malaria treatment to include the community and the home through public
and private, formal and informal sectors, the need for more comprehensive estimates
becomes urgent. Appawu and colleagues (2004) studied malaria transmission dynamics in
the Kassena Nankana District, a site in northern Ghana proposed for testing malaria
vaccines. Intensive mosquitoes sampling was done for one year using human landing
catches in three micro-ecological sites that is irrigated, lowland and rocky highlands.
Transmission was highly seasonal and the heaviest transmission occurred from June to
October. The intensity of transmission was higher for people in the irrigated communities
than the non-irrigated ones. Approximately 60% of malaria transmission in KND occurred
indoors during the second half of the night, peaking at daybreak between 04.00 to 06.00
hours.
CHAPTER THREE
METHODOLOGY
3.0 Introduction
This section of the study looks at the study site, sample population, sample size and the
data collection as well as the mode of analysis.
3.1. POLITICAL BACKGROUND
Bosomtwe District is in the Ashanti Region of Ghana. It was formerly part of the
Bosomtwe-Atwima-Kwanwoma district, but carved out by Legislative Instrument LI 1853
of 29th February, 2008. Kuntenase, the district capital is about 28 kilometers from Kumasi,
the capital of the Ashanti Region. The district shares common borders with the Ejisu-
Juaben district and Kumasi Metropolis on the North; Asante-Akim North district on the
East, Atwima Kwanwoma District on the West and Amansie-East district on the South.
3.2 GEOGRAPHY
The land size is approximately 500 square kilometres which represents about 2% of the
total land area of the Ashanti region. The road network from Kumasi, the regional capital,
to Kuntenase and Abono at the Lake area is second class. Unfortunately, around the Lake
and in most parts of the district the roads are not motorable. There are mountainous areas
as well which are generally quite difficult to access. The district has the only Crater Lake
in Ghana, Lake Bosomtwe which is being developed as a resort to boost tourism in Ghana.
3.3 HISTORY OF THE STUDY AREA
Figure 3.1 shows the map of Bosomtwe-Atwima Kwanwoma district. The map shows the
major towns of the district. The map shows the major towns of the district, roads and the
Lake Bosomtwe.Lake Bosomtwe is one of the biggest lakes in Africa. It can be located in
Ashanti Region of Ghana. ‘Bosomtwe’ means "god of antelope’s. ‘Bosom’ in Akan is god
an antelope in Akan is ‘otwe’. The person who first saw the lake was a hunter. His name
was ‘Agya Bempe’. One day he went out to hunt and he saw an antelope and shot at it. The
antelope ran away, but later on it was found in the lake dead. It was a very small lake. Later
the people thought the antelope was a god so they name the lake after the antelope.
Another school of thought is that the lake came into existence through a volcanic action.
There was valley around the lake side and there were almost thirty villages in the valley
around the lake, but because the lake is getting larger and larger it has covered some of the
villages. The lake has become very big that is why Lake Bosomtwe is among the biggest
Natural Lake in West-Africa and it has now become a tourist attraction fetching Ghana
with foreign exchange.
Lake Bosomtwe was formed by a falling meteorite about 1.3 million years ago. This was
discovered by Rock analysis in 1965 in the USA. Fossils of many animals including lions,
elephants, tigers, black cobras, pythons, and alligators were also found along the rivers
banks indicating that these animals once inhabited the area around the lake. Two rivers and
ground water keeps the water volume of the lake constant. The lake is surrounded by a
peaceful and serene atmosphere (http://africannaturetours.com).
Lake Bosumtwi is a large crater lake formed in an impact crater some 32 km south-east of
Kumasi, Ghana. It is the largest natural lake in Ghana, approximately 8 km across. The
lake is popular as a recreational area.Bosumtwi is a sacred lake to the Ashanti. According
to traditional beliefs, the souls of the dead come here to bid farewell to their god Twi.
Because of this, they only considered it permissible to fish in the lake from wooden planks
(rather than the usual traditional canoes). There are about 30 villages in the lake area, with
a combined population of about 70,000 people.
Lake Bosumtwi is estimated to be 1.07 million years old, placing it in the Pleistocene
period. The crater was easy to find, however, there was a problem in distinguishing whether
it was or was not caused by a meteor impact. This was because it is in the middle of a
rainforest and filled with water to form the lake. The problem with this was that shatter
cones and other rocks and minerals would be deep under vegetation and many of the
features of an impact crater were eroded. However, scientists managed to confirm it was
an impact crater after a dome in the centre, which is common in impact craters, was
discovered buried beneath the lake's floor. The impact is believed to have been a very
powerful one too because tektites have been discovered as far away as the Côte d'Ivoire.
The tektites are believed to have been from the impact.
After the impact the landscape in the area went through several different stages caused by
climate changes. Sometimes periods of heavy rainfall filled the whole crater with water so
the lake level was up to the lowest points of the rim. These periods became obvious when
fossils of fish were found on the top of the hills. The water was even flowing out of the
basin through an overflow channel. But there were also times when the water level was so
low that that rain forest could come up inside the basin and the lake itself was only a small
pond. This period lasted until about 300 years before present.
There is a legend that in 1648 an Ashanti hunter named Akora Bompe from the city of
Asaman was chasing an injured antelope through the rainforest. Suddenly, the animal
disappeared in a small pond, as if the little water wanted to save the animal’s life. The
hunter never got the antelope but he settled close to the water and started catching the fish.
And he called the place “Bosomtwe”, meaning “god antelope”. This story also gives a hint
that by then the lake level was very low, and the dead tree giants standing offshore in the
lake are evidence for it as they are over 300 years old. The following centuries saw several
wars about the lake as both the Ashanti and the Akim people claimed the area to be theirs.
Finally, the Ashanti were victorious and secured Lake Bosumtwi for their kingdom. Each
village in the lake area has its own shrine or fetish grove. With the arrival of Christianity,
some of the people lost their belief in those, but still many are worshipping them for help
in bad times or against diseases. The spiritual centre of the lake is the Abrodwum Stone
(see map). Here, all the lake people will sacrifice a cow when an omen of bad fish harvest
occurs. This act is celebrated in the presence of his majesty, the Ashanti king, the
Asantehene himself. In the ceremony, the guts of the cow will be given to the stone and
the rest is thrown into the lake, so the crowd will rush into the water with cutlasses and
axes to take their share of the meat. This happening is surely worth seeing it, but as the
omen mentioned above depends on various different factors, it is hardly predictable.
3.4 POPULATION
Politically, there are 3 sub-districts, namely, Kuntenase, Jachie-Pramso and Amakom, but
for public health activities, the Jachie-Pramso sub-district has been divided into; Jachie
and Pramso. There are a total of 63 communities with an estimated 2000 population of
96,677.
3.5 STUDY DESIGN AND SAMPLE SIZE
The study was a descriptive cross-sectional study. With a population of 172, 599 and an
estimated 20% of the study population, 200 sample size was determined using EPI STAT
CALC software. Prevalence rate of 23% and a margin of 5% error and a power of 95%
confidence interval.
3.6 DATA COLLECTION AND TOOLS
Prepared questionnaires containing open ended in the form of probing questions and closed
- ended questions were used to interview the clients. The research assistants read out the
questions and interpreted them to the respondents in their local language (Twi) after which
their responses were recorded accordingly. The questions on malaria included the socio -
demographic characteristics such as the educational level, the occupation and the marital
status. Again, questions concerning the causes, prevalence and treatment of malaria were
asked.
3.7 PRE-TESTING
Before the start of the study, pre-testing of data collection tool was carried out at
Ejisu-Juaben, a community in the Ashanti Region of Ghana having similar demographic
characteristics to check for consistency, clarity and the acceptability of the study questions
to the respondents.
3.8 DATA HANDLING AND STORAGE
Questionnaires were numbered serially to allow for easy identification in the sequence in
which they were filled and collected. The identification numbers were kept throughout data
coding. Data were entered on SPSS spreadsheet. SPSS software was used to clean and
validate entered data and for performing the main analysis. Data were stored on laptop and
a backup on a pen drive and a compact disc as well as in the researcher’s electronic mail
inbox.
3.9 ETHICAL CONSIDERATIONS
Ethical approval was obtained from the Committee on Human Research Publication and
Ethics (CHRPE), School of Medical Sciences, SMS, of the Kwame Nkrumah University
of Science and Technology, KNUST and the District Health Management Team (DHMT),
Bosomtwe district. Informed consent was sought from the participants before they were
included in the study. Participants were assured of their privacy and non-participation if
they so wished. Confidentiality of the data and outcome of the study were kept only for the
purpose of the study.
3.10 LIMITATION(S) OF THE STUDY
The study had several limitation, which includes; limited time in collecting data, data
collection assistance were not consistence.
CHAPTER FOUR
RESEARCH FINDINGS
4.0 INTRODUCTION
This chapter analysis and describes the findings of the study. Lake Bosomtwe is Ghana’s
only natural lake. The area is prevailed by malaria. Malaria was defined by WHO (2005)
as a parasitic disease that involves infection of the red blood cells.
4.1 DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS
Malaria is prevalence in the Lake Bosomtwe area. The area is often filled with people with
various background due to the nature of the lake and its historical beginnings. Thus, the
lake serves as a tourist attraction for the nation as a whole.
Plate 1: Overview of Lake Bosomtwe
Source: Microsoft Encarta, 2007
The respondents were grouped into non health official and health officials. The causes,
effects and preventions of malaria vary in terms of age and educational background.
TABLE 4.1 EDUCATION BACKGROUND OF RESPONDENTS
Education Frequency Percentage
No formal education 100 50
Primary 50 25
Secondary 30 15
Tertiary 20 10
Total 200 100
Source: Author’s Field Work, 2007
The educational attainment of the respondents varies greatly. As shown, out of the 200
respondents, both health and non-health official, 100 of the respondents constituting 50%
had no formal education, 50 respondents constituting 25% had primary education, 30
(15%) had secondary education and 20 (10%) had highest form of education.
From the table, it can be estimated that, most of the respondents had no form of education,
therefore have influence on the data collected. The respondents with no level of education
could not actually perceive the causes, effect and prevention of the malaria. As for the
treatment, they were able to contribute. Also, they find it difficult in detecting the
symptoms of malaria from other disease related to them. The respondents who had primary
level of education were able to contribute to the study though they were doubting. Finally
the respondents who had tertiary education contributed to the study greatly to the study.
Due to their level of education, they were able to examine clearly to support the study.
TABLE 4.2: AGES OF RESPONDENTS
Ages Frequency Percentage
18-30 48 24
31-40 32 16
41-50 44 22
51+ 76 38
Total 200 100
Source: Author’s Field Work, 2007
The survey results further shows that age is not fairly distributed among the inhabitants in
the area. The composition of the age structure among the respondents is dominated by the
aged who constitute 38%, within the age group of 51 and above. Also, those within 41-50
years constitute 22%, 31-40 years constitute 16% and 18-30 years constitute 24% of the
study population.
The above table indicated that, the highest age among the respondents ranged between 41-
50,51and above. They were able to contribute to the study. This was due to the fact that,
the old are responsible for the health expenses of their dependants. In addition, the age
range between 18-30 years is the next dominant. The people fall under this age group,
normally is supposed to know the endemic and epidemiology of diseases but this is not the
case. This is attributed to high dropout and low educational level. However, a few were
able to contribute to the study.
TABLE 4.3 OCCUPATIONAL OF THE RESPONDENTS
Occupation Frequency Percentage
Drivers 16 8
Fishermen 16 8
Farmers 98 49
Teachers 5 2.5
Unemployed 50 25
Tourist Attendants 4 2
Retired Government Workers 3 1.5
Nurses 5 2.5
Medical Assistant 3 1.5
Total 200 100
Source: Author’s Field Work, 2007
From the table above 16 (8%) were drivers, 16 (8%) were fishermen, 98 (49%) were
farmers, 5 (2.5%) were teachers, unemployed respondents were 50 (25%), tourist
attendants were 4 (2%), retired workers were3 (1.5%), 5 (2.5%) were nurses and 3 (1.5%)
were medical assistants from the Kuntanase General Hospital. It can be clearly seen that,
majority of the respondents were farmers and fishermen. This is due to the availability of
fertile soil and the lake for fishing. This is the major occupation of the study site.
TABLE 4.4: SEX OF THE RESPONDENTS
Sex Frequency Percentage
Male 120 60
Female 80 40
Total 200 100
Source: Author’s Field Work, 2007
In the Ghanaian society, women are poor, voiceless and vulnerable. As shown in Table 4.4
out of the total respondents, 120 (60%) were male and 80 (40%) were females. The males
are the bread winners in most of the households visited. They were willing to voice out
their perception about the study on behalf of their families. Most of the females who
contributes to the study were single parents who are the heads of their own families.
4.2 MALARIA PREVALENCE
TABLE 4.5: PREVALENCE OF MALARIA
Incidence Frequency percentage
Yes 160 80
No 40 20
Total 200 100
Source: Author’s Field Work, 2007
Table 3.5 shows the occurrences of malaria at the study area. The table shows that,
incidence rate of malaria is very high. This data clearly shows the need for the study in the
Lake Bosomtwe District.
4.3 CAUSES OF MALARIA
TABLE 4.6: RESPONSE ON THE CAUSES OF MALARIA
Causes Frequency percentage
Unsanitary Practises 190 95
Ignorance 10 5
Source: Author’s Field Work, 2007
Malaria like any other infectious disease has so many causes to its existence. At the study
site, unsanitary practises and ignorance were the major causes of malaria. Table 3.6 shows
ignorance which includes (less public education on malaria) constituted 10 (5%) whiles
unsanitary practises which also includes (improper disposed of sewages, weeds and
stagnant water in cans and gutters) constitute 190 (95%). From the table, unsanitary
practises were seen to be the major cause of malaria in the area. These unhealthy practises
help in the breeding of mosquitoes especially the Anopheles mosquito (female mosquito)
(see plate 2).
Plate 2: An Anopheles mosquito
Source: Miscrosoft Encarta, 2007
When the mosquito bites the inhabitants, the mosquito deposits some species of
plasmodium parasites which actually cause malaria in humans. When the inhabitants are
infected, they are characterised by chills and fever mostly.
4.4 EFFECTS ON MALARIA PREVALENCE
TABLE 4.7 RESPONSE OF EFFECT ON MALARIA
Effect Frequent Percentage
Poverty 90 45
Death 20 10
Low Production 40 20
Loss of Weight 50 25
Source: Author’s Field Work, 2007
With the table above, it could be ascertained that, the effects of malaria on the inhabitants
were poverty 90 (45%), death 20 (10%), low production at work 40 (20%) and loss of
weight due to low appetite constituted 50 (25%). From the table, it was deduced that
poverty has the largest effect on the respondents. When the inhabitants get infected, money
and time are wasted in the course of the treatment. More so, when symptoms like chills
and fever resurface the body’s immune system becomes weak leading to low production,
low profit hence poverty.
4.5 TREATMENT AND PREVENTION OF MALARIA
TABLE 4.8 RESPONSE ON TREATMENT AND PREVENTION OF MALARIA
Variables Frequency Percentage
Treatment
Orthodox 190 95
Herbal Medicine 10 5
Prevention
Use of treated mosquito Nets 40 20
Use of mosquito Repellants 50 25
Keeping the environment clean 110 55
Source: Author’s Field Work, 2007
From table 4.8, 190 (95%) of the respondents use orthodox medicine either prescribed by
a medical assistant or bought from the pharmacy. About 10 (5%) use herbal medicine. The
herbal medicine is either bought from the chemist shop or they get them from the native
doctors. The herbal medicine is mostly a mixture of roots, weeds, leaves and herbs from
their surroundings. As the sayings goes, ‘prevention is better than cure.’ This statement is
true because from the above 40 (20%) uses treated mosquito nets as a way to prevent
themselves of getting malaria. About 50 (25%) uses mosquito repellents at night to
prevented getting malaria. Majority of the respondents sought to cleaning and a healthy
environment as a way of preventing malaria from occurring. If all these precautions are
met, the respondents believe that the prevalence o0f malaria in the district would reduce
dramatically. In effect, there would be less death, weight gaining, high production at the
workplace, high income, all resulting to poverty reduction.
4.6 HEALTH OFFICIAL RESPONSES
Among the health officials, there were three (3) medical assistants and five (5) nurses at
the Kuntanse Government hospital. According to the health officials, unsanitary practises
are highly rated in contributing to the prevalence of malaria at the district. Lack of
concentration, poor attitude to work, preterm in babies, and anaemia in pregnancy and
death especially in children are the effects of malaria in the district. According to them,
complying with the treatment of malaria as prescribe by the medical assistant, good
hygiene practises, continue public education on malaria and the use of intercede treated
nets at night will help in the prevention of malaria in the district.
In conclusion the health officials indicated that, 30% of malaria cases are recorded daily,
40% cases recorded weekly, 50% recorded monthly and 60% cases recorded yearly.
According to the health officials, among all the villages, Obo recorded the highest
incidence of malaria cases constituting 62.1% yearly.
CHAPTER FIVE
SUMMARY, CONCLUSION, AND RECOMMENDATIONS
5.1 SUMMARY OF FINDINGS
This study reveals the prevalence of malaria in the Lake Bosomtwe Area in the Ashanti
Region of Ghana by using cross-sectional data collected in February, 2007. This study
specifically assessed the prevalence of malaria, its causes, effects, treatment as well as
preventions in the study areas. The study assed the causes of malaria in the Lake Bosomtwe
area as result of unsanitary practises and ignorance.
The study further reveals that, poverty and death are the effects malaria has on them. It was
justified that, the inhabitants of the study area use both orthodox and herbal medicine in
treating malaria. Also, the inhabitants prevent themselves from getting malaria by the use
of mosquito nets and repellents as well as keeping their surroundings clean.
The key to understanding the potential of the prevalence of malaria is for the government
and health officials to recognise the fact that malaria is a factor to poverty and death in our
societies. Again, malaria is both a preventable and curable. However, this can be done if
greater attention and educational strategies are strictly put in place.
5.2 CONCLUSIONS
The research reveals that, the major causes of malaria are unsanitary practises which
includes; improper disposal of sewage, weeds stagnant water in cans and gutters and
ignorance in terms of less publicity on malaria. That is, most of the inhabitants are not
aware of the causes and preventions of malaria. Therefore, they are not able to avoid the
getting malaria. Also the improper disposal of waste and stagnant water in cans serves as
a catalyst for breeding of mosquitoes.
It was revealed that, poverty, death, preterm in babies, anaemia in pregnancy and loss of
weight, low productivity at work, low concentration especially in children are the effects
of the occurrences of malaria at the study site. Finally the study shows that, inhabitants
seek orthodox and herbal medicines in the treatment of malaria. In addition, malaria can
be prevent by the use of mosquito nets and repellents as well as keeping their surroundings
clean.
5.3 RECOMMENDATIONS
According to Turkington (2006), malaria is a serious, infectious disease spread by certain
mosquito usually the Anopheles. Malaria ranks among the major health and development
challenges facing the world. The Lake Bosomtwe is a tourist area, of which day in and day
out a lot people visit and stay, therefore there is a need for appropriate measures to be taken.
Based on the research findings, particularly the constraints identified, the following
suggestions are made for the prevention of malaria at the Lake Bosomtwe district of the
Ashanti Region;
Incidence of malaria should be reported very early and patients should comply with
treatment as required by the medical assistants.
Homes and surrounding environment should be kept clean: sewages must be
properly disposed, weeds must be cleared often and stagnant water in gutters and
cans should be kept dried.
There should be communal labour in the village around Lake Bosomtwe district.
The use of treated mosquito nets and repellents should be used often at night and
day time as precaution against mosquito bites.
Government should give out free mosquito nets and implement policies to cater for
children who suffer from malaria.
Preventive medicines such as Daraprin and Malaprin should be taken weekly.
Also, inhabitants should be vaccine against the infection using CS antigens and
gametocyte antigens.
Lastly, government and other institutions such as non-governmental agencies
should make it their ultimate aim of publicizing the awareness of malaria, thus, it
causes, effects, treatment and prevention.
5.4 LIMITATIONS
The inhabitants of the villages were very busy at the time of data collection. Some were
running their business whilst most of them were at funerals either within or outside the
district. Due to these reasons, not all categories of people were interviewed, though
random sampling was used in the study.
5.5 SUGGESTIONS FOR FUTURE RESEARCH
Future research could consider the whole of Ashanti Region since the regions is noted
for high incidence of malaria cases.
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